R&R In The FASTLANE 067

Welcome to the 67th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

DRAFT Clinical Policy:Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.  The draft is now open for comments until March 13, 2015. To view the draft policy and comment form, Click Below: Clinical Policy Comment Form-Intravenous tPA 

• ACEP has revamped it’s recommendations for the most controversial topic in Emergency Medicine: the use of tPA in acute ischemic strokes. The draft for the new clinical policy is available online, and importantly, there is a comment period open for 60 days (until March 13th). While there are strong feelings on both sides of this debate, the ability to make our voices heard within the organization is an important opportunity, and not to be missed.Briefly, the new policy examines the same two questions as the one from 2012:
• 1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset
• 2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?Important changes in the policy include
  • A new emphasis on a shared decision making model with the physician and patient as a Level C recommendation
  • The specific mention of consideration of the increased risk of symptomatic intracerebral hemorrhage as the ONLY Level A recommendation
  • The strength of the recommendation for tPA toned down from “should be offered” and “should be considered” in the 2012 policy to “may be given to carefully selected acute ischemic stroke patients” in the new one.
  • Overall, a must read piece for EM practitioners, not only to inform their own decision making, but also to give voice to our own thoughts on the issue prior to publication of the policy.
• Recommended by: Jeremy Fried
• Read More: The Wholesale Revision of ACEP’s tPA Clinical Policy (EM Lit of Note)
• Read More: Reflections on ACEP tPA Clinical Policy Update Draft (FOAMCast)

Fraser K et al. The Emotional and Cognitive Impact of Unexpected Simulated Patient Death A Randomized Controlled Trial. Chest. 2014; 145(5): 958-63. PMID: 24158305

• What is the effect of simulation patient death on trainees? This study looks into the question and finds that medical students randomized to having their simulated patient die report increased cognitive load and had poorer learning outcomes. The authors caution that this doesn’t mean we shouldn’t have simulated patients die but that we need to plan for this outcome intelligently.
• Recommended by: Anand Swaminathan

Calle PA et al.  Inaccurate treatment decisions of automated external defibrillators used by emergency medical services personnel: Incidence, cause and impact on outcome. Resuscitation 2015. PMID: 25556589

• This is an interesting and concerning paper. Two authors reviewed all rhythm analysis algorithm (RAA) from patients who had an AED activated secondary to cardiac arrest. The authors found that in 16% of shockable rhythms (23 of 148) the AED did not advise shock, often secondary to artefacts or “fine V-fib”.This article shows a concerning incidence of “failure to defibrillate” among OHCA receiving AEDs.
• Recommended by: Daniel Cabrera

Maffei FA et al. Duration of mechanical ventilation in life-threatening pediatric asthma: description of an acute asphyxial subgroup. Pediatrics 2004; 114(3):762-7. PMID: 15342851

• Interestingly, while we often preach to not intubate the asthmatic… there may be a sub-population of patients with Acute Asphyxial Asthma who have brief, albeit severe, exacerbations that require intubation, but then do fairly well. These patients may present to you with no other option than to intubate.
• Recommended by:  Sean Fox

Pener A et al. Scandinavian clinical practice guideline on choice of fluid in resuscitation of critically ill patients with acute circulatory failure. Acta Anaesthesiol Scand. 2014. PMID: 25363535

• Scandinavian guidelines for fluid resuscitation in critically ill patients. For general ICU patients, those with sepsis and trauma patients crystalloids rather than hydroxyethyl starch, gelatin and albumin are recommended . Unfortunately no recommendations are provided for burns as there are very limited data from randomised trials on fluid resuscitation in this patient population.
• Recommended by: Soren Rudolph

Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2014 Nov 10. PMID: 25388828

• Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a form of high flow nasal cannula – provided oxygen therapy. High flow rates, a degree of PEEP, and potentially some CO2 clearance can be achieved, and so it might be a more effective alternative to routine nasal prong oxygenation during apnoea after RSI (ie. an alternative form of NODESAT). The bulkiness of the apparatus can make it difficult to provide mask ventilation and more studies are needed to define patients who might benefit, but this small elective anaesthesia study on patients with difficult airways provides an interesting overview of the technique.
• Recommended by: Cliff Reid
• Read More: High flow systems for apnoeic oxygenation (RESUS.ME)